Government Services Division

Please write clearly and return this application via email to:

Novated Vehicle Lease Facility Category Manager

Email :

APPLICATION TO PREQUALIFY FOR THE

NOVATED VEHICLE LEASE FACILITY REGISTER

Applicants seeking to participate on the Novated Vehicle Lease Facility Register are requested to complete and submit the Application and Checklist of Documents.

Section 1 - Organisational Details

Full legal name of Applicant:

If you are a company acting as a trustee,

provide your name in this format,

(e.g. ABC Pty Ltd as trustee for the XYZ Trust)

Business or Trading Name

Australian Company Number (ACN)

Australian Business Number (ABN) ….

Registration Number

(incorporated association applicants only)

Applicant Type:

¨ Proprietary Company ¨ Public Company ¨ Sole Trader ¨ Trust ¨ Incorporated

Association ¨ Union ¨ Partnership ¨ Other (please specify ………………………………

Australian Credit Licence (ACL)

or Australian Financial

Services Licence (AFSL) Number

Section 2 - Applicant Contact Details

Registered Office Address:

(PO Box is not acceptable)

Address of principal place

of business (if different to above)

Name of Contact Person:

Position: …………………………………..

Phone Number: ………………………………………………………………. .

Fax Number: ………………………………….

Email:

Section 3 - Financial Viability

Applicants are requested to demonstrate that they have the financial capacity to provide, over the life of the Facility, all the requirements specified by the Department (or a Participating Agency). Accordingly, you are required to provide the following information.
If the answer to any of the following questions is “yes” your application may not be considered successful.
(a) Are there any significant events, matters or circumstances which have arisen since the end of the last financial year which may significantly affect the operations of the Applicant? /

(a) 

(b) Are there any mergers/acquisitions either recent (within the past 12 months) or which are imminent that may significantly alter the Applicant’s corporate structure? /

(b) 

(c) Are there any proceedings, either actual or threatened, against the Applicant or any director of the Applicant, or have there been any such proceedings within the past five years? If so, what (if any) remedial action has been taken in respect of such proceedings? /

(c) 

(d) Are there any bankruptcy actions against a director of the Applicant, its parent or associated entities, or has there been within the past five years? /

(d) 

(e) Are there any de-registration actions against the Applicant, its parent or associated entities on foot, or have there been any within the past five years? /

(e) 

(f) Are there any insolvency proceedings, actual or threatened (including voluntary administration, application to wind up, or other like action) against the Applicant, its parent or associated entities on foot, or have there been any within the past five years? /

(f) 

(g) Is the Applicant, its parent or associated entities currently in default of any agreement, contract, order or award that would or would be likely to adversely materially affect the financial capacity of the Applicant? /

(g) 

(h) Are there any other factors which could adversely impact on the financial ability of the Applicant? /

(h) 

(i) Is the Applicant solvent and able to meet its debts as and when they fall due in the normal course of business? /

(i) 

In addition to the information required above, Applicants are required to undertake to provide to the Department (or a Participating Agency) upon request all such information as the Department (or the Participating Agency) reasonably requires to satisfy itself that Applicant is financially viable and have the financial capability to continue to provide the Novated Vehicle Lease Facility.
Provide your undertaking to comply with this request. /

(j) 

Section 4 – Conflict of Interest
Provide details of any interests, relationships or clients which may or do give rise to a conflict of interest and the area of expertise in which that conflict or potential conflict does or may arise and details of any strategy for preventing conflicts of interest.
Outline the processes of the Applicant which are in place to handle any future conflict of interest (actual or perceived).
Section 5 – Insurance
The Applicant must obtain and maintain insurance coverage at all relevant times sufficient to cover any loss or costs that may be incurred and for which the Applicant is liable in connection with the provision of the Facility Services. On request, the Applicant must provide the Department or a Participating Agency with evidence of the currency of any insurance it is required to obtain.
Provide details of all relevant insurances maintained by the Applicant. / Name of insurance company:
______
Public and Product Liability:
______
Policy number(s):
______
Expiry dates:
______
(a) Limit of liability:
______
(b) Relevant exclusions:
______
Provide details of all relevant insurances maintained by the Applicant. / Name of insurance company:
______
Professional Indemnity:
______
Policy number(s):
______
Expiry dates:
______
(a) Limit of liability:
______
(b) Relevant exclusions:
______
Provide details of all relevant insurances maintained by the Applicant. / Name of insurance company:
______
Other:
______
Policy number(s):
______
Expiry dates:
______
(a) Limit of liability:
______
(b) Relevant exclusions:
______
Section 6 – Specification
An Applicant must undertake a self-assessment of its compliance with the Specification (“Novated Vehicle Lease Facility Specification”) by completing the separate tabulated form of the Specification.
Does the Applicant satisfy the minimum requirements set out in the Specification and agree to comply with the Specification during Prequalification:
 Applicant will comply
 Applicant will not comply
Section 7 – Prequalification Terms
For the purposes of the Prequalification Terms, the Applicant has read and agrees to be bound by the Prequalification Terms applicable to the Register for which the Supplier seeks Prequalification in this Application.
 Applicant agrees
 Applicant does not agree
Section 8 – Warranty
The Applicant warrants to the Department that any information provided by the Applicant as part of or in connection with the Application is accurate, current and complete and not misleading or deceptive.
 Applicant warrants
 Applicant does not warrant
Section 9 – Please read and sign below
The Applicant acknowledges and agrees that, if granted admission to the Register, the terms and conditions of the Prequalification will be those of the Prequalification Terms. The Applicant confirms its acceptance of the Prequalification Terms and agrees to be immediately bound by the Prequalification Terms upon its execution below.

SIGNED FOR AND ON BEHALF OF THE APPLICANT

Signed: …………………………………………………………….. Date: …………………………….

Print Name: ………….……………………………….……………………….

Position*: ………………………….…………………….……………………..

*To be signed by a Director/Partner or other authorised person representing the Applicant

WITNESS

Signed: …………………………………………………………….. Date: ………………………….

Print Name: ………….……………………………….……………………….

Position: ………………………….…………………….……………………..

I/we accept the following

CHECKLIST OF DOCUMENTS þ

To be completed by the Applicant

1. / COMPLETED APPLICATION FORM
2. / PROVIDED DETAILS OF:
·  INSURANCE
·  CONFLICT OF INTEREST
·  FINANCIAL VIABILITY
3. / UNDERTAKEN A SELF-ASSESSMENT OF COMPLIANCE WITH THE PREQUALIFICATION TERMS
4. / UNDERTAKEN A SELF-ASSESSMENT OF COMPLIANCE WITH SPECIFICATION
5. / REVIEWED AND APPROVED THE USE OF THE VICTORIAN GOVERNMENT’S DEED OF NOVATION IN CONNECTION WITH THE FACILITY SERVICES
6. / COMPLETED THIS CHECKLIST OF DOCUMENTS

Signed: …………………………………………………………….

Date: ……………..